Failure to Provide Private Telephone Access for Residents
Summary
The facility failed to ensure that residents on the locked unit had the opportunity to make and receive phone calls without being overheard, as required by their own policy. Residents who did not possess their own phones were required to use the telephone located in the nurses' office, where privacy could not be guaranteed. Staff were typically present in the office during resident calls, and the phone's location and short cord length further limited privacy. Residents reported that staff rarely offered privacy, and even when requested, staff would leave the door ajar to monitor the resident, allowing conversations to be overheard in the hallway. Multiple residents on the locked unit, including individuals with schizoaffective disorder, ADHD, and autistic disorder, expressed dissatisfaction with the lack of privacy during phone calls. These residents indicated that they would prefer to have private conversations but were not provided with a means to do so. The facility previously had a portable phone that allowed residents to make private calls, but this was discontinued about a year prior when a new phone system was installed. Since then, no alternative arrangements for private phone access had been made for residents without personal phones. Staff interviews confirmed that the only phone available for resident use was in the nurses' office and that staff presence was standard unless privacy was specifically requested. Even then, privacy was limited due to the need to keep the door ajar for supervision. There were also informal restrictions on when residents could use the phone, depending on staff availability, and some staff imposed time limits on calls. The facility's administration and nursing leadership acknowledged these practices and the absence of a portable phone, but no clarification or alternative had been provided to ensure residents' right to private communication.
Penalty
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Residents did not receive mail on weekends because mail delivered by USPS on Saturday was held until Monday. During a resident council meeting, residents said there was no one to pass out the mail. The SSD was unsure of the process, the Bookkeeper said mail was stored in a locked room and given to the ADM on Monday, and the ADM stated resident mail should be given out when received but there was no policy directing staff on Saturday mail handling.
Delayed Resident Mail Delivery: A resident interview and staff statements showed that mail arriving on Saturday was held until Monday instead of being delivered within 24 hours. Two cognitively intact residents confirmed the delay, and the facility mail policy stated that Saturday deliveries were included in the 24-hour delivery expectation.
A facility failed to ensure residents and family members had reasonable access to phone communication. Family members reported repeated unanswered calls, long holds, and no way to leave messages, while a resident stated he could not get staff to answer when he called for help. The administrator said daytime calls were handled by Medical Records and after-hours calls by clinical staff, but there were no cordless phones, no full-time receptionist, and no voicemail box, and staff reported dozens of missed calls.
Resident mail and packages were opened by staff without permission, despite the facility’s resident rights policy stating residents must receive unopened private mail. An Activities Director and an LPN said staff had been instructed to open mail or packages if they had concerns about the contents, and three cognitively intact residents reported that their mail had been opened before delivery, with one resident saying it made her feel her privacy was violated.
Resident Mail Not Delivered Timely: A resident reported a package delivered on a Saturday was left by the front door until the next day. Interviews showed the weekend mail process was inconsistent, with the BOM, AD, receptionist, HR, and DON giving conflicting accounts of who was responsible for sorting and delivering resident mail. The facility policy stated resident mail should be delivered unopened and sorted to the resident's room.
Failure to Deliver Resident Mail on Weekends: The facility did not ensure residents received mail on weekends. A group of residents stated Saturday mail was not distributed until Monday, and the AD, BOM/HR, and ADM confirmed there was no one designated to deliver weekend mail. The BOM/HR stated mail was handled Monday through Friday, while the ADM said the expectation was for unopened mail to be delivered on the weekend.
Delayed Weekend Mail Delivery
Penalty
Summary
Residents did not receive mail in a timely manner because mail received on Saturdays was not delivered to them. The facility's Resident Rights, revised 01/2017, stated that residents have the right to access private communication of all kinds. During a Resident Council Meeting on 06/23/2026, eleven residents stated that they did not receive mail on the weekend, and when asked why, they said there was no one to pass the mail out. On 06/25/2026, the Social Services Director stated she was not sure how Saturday mail was handled and said no one worked in the business office on Saturdays. The Bookkeeper stated the postman brought mail to the main station, staff stored it in a locked room, and it was given to the Administrator on Monday morning before being delivered to residents. The Administrator stated USPS did deliver mail on Saturday, that resident mail should be given to residents when received, and that there was no policy directing staff on what to do with resident mail received on Saturday.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods because mail was not delivered to residents on Saturdays. Two cognitively intact residents stated during interview that mail arriving on Saturday was not delivered until Monday, and one resident confirmed that mail delivered to the front desk on Saturday was sorted and delivered on Monday. The front desk receptionist and business office manager stated that during the week they deliver mail to residents, but on Saturday residents can only come to the front desk to get expected mail, and otherwise the mail is held and delivered through the facility on Monday. The facility policy stated that mail and packages are to be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries.
Telephone Access and Call Response Failures
Penalty
Summary
The facility failed to ensure residents had reasonable access to telephone communication and privacy in their use of communication methods for four residents reviewed for telephone communication. Family members and residents reported repeated difficulty reaching the facility by phone, including calls that rang without answer, calls that were not returned, and long holds when calls were answered. One resident stated he had tried to call the facility for help and could not get anyone to answer, and a family member reported the resident had to call her so she could contact the building to reach staff. The administrator stated he had been made aware about a month earlier of an issue involving a resident's family member being unable to get through after hours. Medical Records answered phones during weekday daytime hours, while clinical staff, including nurses and CNAs, were responsible after hours. The facility had no mobile or cordless phones, only phones at nurse's stations and in offices, no full-time receptionist, and no voicemail box set up for callers to leave messages. The Medical Records/Receptionist staff member stated there were times she arrived to find 50 or more missed calls on the phone and that family members sometimes reported they could not get anyone after she left for the day.
Resident Mail Opened Without Permission
Penalty
Summary
The facility failed to ensure residents were permitted to receive unopened mail and packages and failed to protect residents’ privacy and confidentiality for three residents who were interviewed about mail receipt. The facility policy, Resident Rights Policy, stated that every resident has the right to be treated with consideration and respect for personal privacy and to receive unopened private mail. During interviews, the Activities Director stated she had opened mail addressed to residents in the past and had been instructed to do so to make sure residents were not ordering items that could be hazardous to their health. She also said nursing staff had been told it was acceptable to open resident mail at their discretion if they suspected a package contained something suspicious. LPN #3 acknowledged that staff opening resident mail was a facility practice and said the Social Services Director and other staff had been instructed to open resident packages if they had concerns about the contents. Resident #32, who had a BIMS score of 14 and was cognitively intact, reported that packages from her brother were sometimes opened before delivery and retaped, leaving her unsure whether items had been removed. Resident #3, who had a BIMS score of 15, stated staff opened his mail and told him they had always been told it was acceptable. Resident #9, who also had a BIMS score of 15, reported that some of her mail had been opened before delivery and said it made her feel terrible and violated her privacy. The Administrator stated he was unsure where staff got the idea they could open residents’ mail without permission and acknowledged that doing so violated residents’ privacy rights.
Resident Mail Not Delivered Timely
Penalty
Summary
The facility failed to ensure residents had reasonable access to receive their mail in a timely manner. Confidential Resident #1 reported that a package delivered on a Saturday was left by the front door until the resident retrieved it the following day. The report states the facility did not have a consistent system in place to distribute incoming mail daily, and the weekend process for handling resident mail was unclear and inconsistently carried out. During interviews, the BOM stated that during the week she retrieved the mail and gave it to the AD for distribution, while on weekends the weekend receptionist was supposed to obtain and deliver the mail to residents. The AD stated that the weekend receptionist was responsible for distributing mail, but Receptionist L stated she obtained the mail on weekends and did not distribute it to residents, instead placing it in HR's office box because she was new and unfamiliar with the residents. HR stated she did not distribute mail on weekends and had not seen resident mail in her office box, while the DON stated the weekend process was that HR checked the mail, provided it to Receptionist L, and Receptionist L distributed it to residents. The facility policy stated resident mail would be delivered unopened and sorted and delivered to the resident's room.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not delivering mail to residents on weekends. During a confidential group interview, 9 of 13 residents stated that mail was not distributed on Saturdays and was not delivered until Monday or picked up until Monday. The deficiency involved the facility's handling of resident mail, including mail delivered on the weekend being left in the mailbox rather than being given to residents. During interviews, the AD stated weekend mail stayed in the mailbox because staff had been instructed by the BOM/HR not to touch it, and that the mail would be picked up on Monday or by the AD. The BOM/HR stated mail was delivered to residents Monday through Friday and that there was no one designated to pass mail on the weekend, although she acknowledged it was a resident right to receive mail on the weekend. The ADM stated that prior to the survey there was nobody designated to deliver mail to residents on the weekend and that the expectation was for mail to be delivered unopened on the weekend.
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